Addressing stigma, disparities in minority mental health:

Access to care among barriers

When Dior Vargas was growing up, she dealt with major depressive disorder. And while she has gotten treatment for depression throughout her life, when she hears about it in the media, the people dealing with mental illness never look like her.

“I always felt like I was the only one, and like I didn’t have anyone to turn to and talk to,” said Vargas, MS, a New York City resident who describes herself as a Latina feminist mental health activist. “I felt like I was alone. When people talk about mental illness, when it’s discussed or shown through the media, they never really show people of color. That’s…why I felt alone.”

Vargas is one of a growing group of mental health advocates who are fighting against stigma and disparities for minorities who face mental illness. And the disparities and stigma are truly a problem, said Larke Huang, PhD, director of the Office of Behavioral Health Equity at the Substance Abuse and Mental Health Services Administration. Huang says that minority populations face prevalence of mental illness at about the same rate as whites do. However, racial and ethnic minorities — as well as lesbian, gay, bisexual and transgender people — face greater mental health risks and burden of the disorders because of disparities working against them.

Poverty plays role in mental health stress

One of the major risk factors for increased stress and mental health issues is poverty, Huang told The Nation’s Health.

“People of color are disproportionately represented in poverty, either below the poverty level, at the poverty level or just above it,” Huang said.

She also pointed out that people of color are more likely to hover near the poverty line, bouncing from under to over throughout their lives, noting that “With poverty, there’s…post-traumatic stress disorder, depression, anxiety.”

Huang said that studies have shown that when individuals and communities are lifted out of poverty, mental health improves. In a 2003 study published in the Journal of the American Medical Association, researchers surveyed a sampling of children in poverty, including a population of American Indian children and families living on a reservation, who had a variety of mental health issues. When a casino was opened on the reservation where the researchers were sampling, some of the children and their families moved out of poverty to a middle-income level. Among those families, children’s mental health issues, in particular conduct and oppositional defiant disorders — which the Mayo Clinic describes as “persistent pattern of tantrums, arguing and angry or disruptive behavior toward authority figures” — dropped to the same level as children who had never lived in poverty.

But along with poverty, access remains a major issue adding to mental health disparities among minority populations. Access, Huang said, can be defined in many ways. Access to mental health professionals might be limited by a person’s insurance status, for example — more than half of U.S. residents without health insurance are people of color, Huang said.

Access goes beyond meeting with a specialist. Huang pointed to “enabling services” that need to align in order for a person to get mental health care. These can include transportation, child care, time off from work and other issues that people seeking mental health care might need in order to make and keep an appointment with a mental health professional, or even their primary care provider.

“We see life stress events that get in the way…of people completing treatment,” Huang said. “People who are limited in resources often have a difficult time getting to or keeping appointments. (We also see) discrimination and racism creating stress responses and traumatic experiences, that can also lead to reduced capacity to cope, to adjust and to seek care when needed.”

Shortage of care often barrier for minorities

For minorities facing mental health issues who do seek treatment, there are further roadblocks to their care. For one thing, there is a lack of sufficient mental health professionals working in the public health system — in community health clinics or for county departments of mental health, for instance. Huang called the shortage “significant.”

But culturally competent care might be an even bigger hurdle for those seeking care. Stigma can make people reluctant to discuss their mental health needs with friends or family, or even their health care providers. Providers need to be trained to understand the populations they serve, Huang said — and to understand the differences and different needs between and within groups. For example, within the Asian-American population, Korean Americans face psychological distress at different rates than Filipino Americans, according to the U.S. Department of Health and Human Services’ Office of Minority Health.

Shortages such as these also point to the lack of diversity among those being trained as mental health professionals, Huang said. People of color are more likely to serve communities similar to the ones they grew up in, and bring their own experiences to the care they provide.

If health care providers are not trained to recognize and treat issues for the populations they serve, Huang said, it can lead to negative health outcomes, including high dropout rates for care.

“Various studies have shown that people of color report more dissatisfaction with the care,” she said. “(We see) high rates of dropout because there is a feeling that they are not totally understood by their providers.”

Huang also mentioned that peer mentors who have experienced mental health problems and who are in recovery are valuable sources of support and can help to address the workforce shortage.

Taking action: How advocates can help

At national and local levels, public health advocates are taking steps to remove disparities and provide care to communities that most need it. At SAMHSA, Huang said, the Office of Behavioral Health Equity was created as a result of the Affordable Care Act to address disparities and promote quality care for all who need it.

SAMHSA also looks at its grantees to ensure that its funds are spent equitably. Each entity that receives a SAMHSA grant must provide disparities impact statements.

“If we have a jail diversion program, who is getting into that program?” Huang offered as an example. “Is it 80 percent white and only 10 percent black? How do the outcomes differ? It’s our attempt to really say, ‘Are our investments really reaching populations of color and are they doing equally well?’”

Activist Dior Vargas has created a photo project encouraging minorities to share their mental health issues.

Photo courtesy Dior Vargas

Putting more culturally competent care providers into the field could also help. SAMHSA’s Minority Fellowship Program, which works to reduce health disparities and improve health care outcomes of racially and ethnically diverse populations, trains an average of 120 mental health practitioners each year — including Huang. More than 600 psychologists of color have been trained through the program, she said.

And care providers can go beyond just mental health professionals. The National Network to Eliminate Disparities in Behavioral Health, formed with support from SAMHSA in partnership with the National Alliance of Multi-Ethnic Behavioral Health Associations, works to provide evidence-based science and training to community-based organizations that work with minority populations. More than 700 community-based organizations are now part of the network, Huang said.

“(We work to) expand the workforce…so they can more capably work with minority populations of color presenting with mental health issues, so we can diminish dropout rates and increase the positive outcomes of care,” Huang said.

And some organizations and individuals are working on smaller levels to fight stigma in their communities. Each year, some of these groups or individuals are recognized by the American Psychiatric Foundation’s Awards for Advancing Minority Mental Health.

Vargas is combatting the stigma and loneliness some people face with her “people of color and mental illness photo project.” Hosted online at www.diorvargas.com, but with plans to take the project offline to bookstores and galleries in neighborhoods of color, Vargas and other people of color share photos of themselves, identifying themselves and the mental health issues they face.

Vargas said she chose a photo project because of its accessibility and potential reach.

“It’s simpler, because not everybody has access to video,” she told The Nation’s Health. “A picture’s worth a thousand words. I definitely want to take it to different mediums…so that people can go to it and…view it in person. I’m using my experience to turn it into a positive one for others, and to bring a conversation about this topic.”